SEL AND HYSTERECTOMY SINGLE ENTRY LAPAROSCOPY AND HYSTERECTOMY ETCA

Introduction
Laparoscopy did start with the SEL (Single Entry Laparoscopy) first diagnostic and later with Palmer using his “ Work laparoscope” both for sterilization, at that time with uni-polar electro surgery and small operative gestures. At almost the same moment in time Kurt Semm did realize that when gynaecologists wanted to perform the operation they performed by laparotomy we were in need of more instruments and hence of more openings in the abdominal wall. He introduced the multiple entries. If we could realize a combination between the two we would then be talking about “Back to the future”.

Technique

An skin incision of 2.5 cm is made deep in the umbilicus.

A Veress needle of 18 – 20 cm is used to create a pneumoperitoneum of 20 mm Hg . CO² gas is used at a continuous flow of 4.5 lit a minute. An intra- abdominal balloon is created in this way allowing a safe opening of the abdominal cavity.

The fascia of the musculus rectus abdominus is incised and grasped, the peritoneum is opened.

An open laparoscopy technique is used to grasp the peritoneum under the fascia.

This peritoneum and the overlying fascia are incised over some 4-5 cm.

The Single Entry Port is introduced into the abdominal cavity after checking with the fingers that no bowel is adherent to the incision site.

After the way of access is created a scope, 30-45°, is introduced followed by the necessary instruments needed to perform the surgery.

Conventional long or specific instruments are used.

As smoke can be a problem it is advisable to use sealers as these bipolar instruments of the sixth generation produce less smoke.

MaterialSEL PORTS
Different ports can be used. The authors do use the disposable port of Covidien ( Norwalk Connecticut USA), the SILS.

A silicone port is introduced into the abdominal cavity. The choice is one of two ports of five mm and one of 12 mm or one of four 5 mm ports. For hysterectomy the authors prefer a SILS with one 12 mm port for the introduction of a high cap trocar and a ten mm trocar as to maintain a CO² delivery of over twenty liters a minute.
The other port is the X-Cone (Karl Storz Gmbh & Co Tutlingen Germany).

The advantage of this port of entry is that is not disposable. Here five ports can be used varying from 5mm through 10 mm.

SEL INSTRUMENTS
The instruments have to be adapted to the use through SEL ports. These have to be longer than the usual instruments as all have to be used through the umbilicus. The characteristics of the instruments have to be so that these do not clash with the optic. Therefore it is easier to have or double bended instruments, most of these are multiple use ( Karl Storz Gmbh & Co Tuttlingen Germany) or single use instruments that can be bend into the correct position during the operation(Covidien Norwalk Connecticut USA).

Scopes have to be adapted. The most frequently used are scopes of 5 mm 30° final lens of 50 cm. The length of the scope avoids clashes with the instruments.

The long 5 mm scope is seen on the left of the picture. A long single bend instrument is seen central whilst a double bend instrument is seen on the right.

The aim of designing or bending the instruments during the surgery in this way is to be able to aggress the objects – the target tissues – in the correct plane to be able perform the necessary manipulations (1). In the other picture single bend instruments can be seen. Sometimes a single bend is enough to perform the manipulation. The preference depends on the type of instrument and the ability of the surgeon to localize the instrument in space. The localization in space of the instruments is easier with single use instruments that can be bend to a specific position in space during the intervention. Multiple use instruments do not have this specific property and hence the surgeon needs more intuition to locate the instrument in the given space.

Benefits

The technique allows for a easy conversion to conventional laparoscopy.

There is less postoperative pain.

The recovery time is faster.

There are less postoperative complications.

The cosmetic results are even better than conventional laparoscopy.

On the macro economical scale there is a speedier return to the classical activities.

Disadvantages and Complications
According to literature search there are:

Bleeding complications is 2 %.

Infections of the abdominal wound in 2%.

Injury to other organs in 1%.

Herniation at the incisional site less than 1 %.

Conversions to traditional laparoscopy 5-10%.

Conversion to open surgery 2 %.

Longer operating time 20-45%.

There are additional cost to instrument and training difficult to evaluate but substantial.

The way of access is not yet Evidence Based.

Comparison between the types of surgery to perform hysterectomy

Contraindications
At this moment in time there are still some contraindications as to perform SEL hysterectomy:

BMI of more than 30.

Prior abdominal surgery.

Concomitant medical conditions.

Emergency surgery.

All these are relative contra indications mainly dependent on the experience of the surgical team.

Pre Requisites to perform SEL
As this is an advanced form of laparoscopic surgery the technique should be reserved to :